Nursing Elites

1. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?

• A. Monitor the client's IV site for thrombophlebitis
• B. Administer flumazenil to the client
• C. Evaluate the client for further suicidal behavior
• D. Initiate seizure precautions for the client

Correct answer: B

Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Monitoring the IV site for thrombophlebitis (choice A) is important but not the next immediate action. Evaluating the client for further suicidal behavior (choice C) is important but not the priority at this moment. Initiating seizure precautions (choice D) is not the priority action in this scenario.

2. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Weight loss.
• B. Bradycardia.
• C. Peripheral edema.
• D. Dry cough.

Correct answer: C

Rationale: The correct answer is C: Peripheral edema. In right-sided heart failure, the heart struggles to pump blood efficiently, leading to fluid backup in the body. This fluid retention commonly manifests as peripheral edema, causing swelling in the legs, ankles, and feet. Choices A, B, and D are incorrect. Weight loss is not typically associated with right-sided heart failure; bradycardia (slow heart rate) is more commonly seen in conditions like hypothyroidism or athletes, not specifically in right-sided heart failure; and a dry cough is more commonly associated with conditions like pneumonia or bronchitis, not typically with right-sided heart failure.

3. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?

• A. Apply a dry dressing.
• B. Cleanse the wound with normal saline.
• C. Perform debridement as needed.
• D. Apply a hydrocolloid dressing.

Correct answer: D

Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.

4. A client with heart failure is being educated by a nurse about fluid restrictions. Which of the following instructions should the nurse include?

• A. Limit your fluid intake to 3 liters per day.
• B. Increase your fluid intake to 5 liters per day.
• C. Avoid drinking more than 1 liter of fluid per day.
• D. You can drink as much fluid as you want during meals.

Correct answer: C

Rationale: The correct answer is C: "Avoid drinking more than 1 liter of fluid per day." Clients with heart failure are typically advised to limit their fluid intake to around 1 liter per day to prevent fluid overload, which can worsen their condition. Choices A, B, and D are incorrect because they suggest fluid intakes that are higher than the recommended limit, which could lead to fluid retention and exacerbate heart failure symptoms.

5. A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?

• A. Serum glucose level.
• B. Serum calcium level.
• C. Lymphocyte count.
• D. Serum potassium level.

Correct answer: A

Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, elevated cortisol levels lead to increased gluconeogenesis, insulin resistance, and breakdown of proteins and fats, resulting in elevated blood glucose levels. This is known as hyperglycemia. The other options, including serum calcium level (choice B), lymphocyte count (choice C), and serum potassium level (choice D), are not typically affected by Cushing's disease. Therefore, they are incorrect choices.

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